Allegheny Health Network

AUTHORIZATION FOR RELEASE AND DISCLOSURE OF HEALTH INFORMATION PURSUANT TO HIPAA

I, or my authorized representative, request and/or permit the disclosure of any pertinent health information by The National Kidney Registry and Allegheny General Hospital to facilitate kidney donation.

I understand that:

This authorization is voluntary.

I have the right to revoke this authorization at any time in writing,
except to the extent that action has already been taken based on this
authorization.

Communications may be electronic, such as e-mail, and such
methods may not always be secure. There is no guarantee,
assurance, or warranty of confidentiality.

I agree to hold The National Kidney Registry and Allegheny General Hospital harmless from any claims or
liabilities that may result from the electronic communications.

This authorization includes disclosure of information that may relate
to alcohol use, drug use, mental health, and infectious disease information.